Smarter colorectal screening could improve senior health

VA, the nation's largest integrated health system, Medicare and many private insurers use quality measures to encourage screening among 50- to 75-year-olds.

But the use of simple age cut-offs in these quality measures may contribute to what researchers found was underuse of screening in healthy, older people and overuse in unhealthy, older people, according to the study using 2010 data on 399,067 VA enrollees.

An unhealthy, 75-year-old -- whose life expectancy is estimated at less than five years -- was significantly more likely to undergo screening than a 76-year-old who's in good health, according to the study published in BMJ.

"The way quality measures are defined has important implications for how care is delivered," says lead study author Sameer Saini, M.D., a research scientist at VA-CCMR and assistant professor of internal medicine at the U-M Health System. "By focusing on age alone we're not screening everyone who's likely to benefit and some people who are not likely to benefit are being screened unnecessarily, like those with severe health problems.

"If quality measures focused on age and health status, rather than age alone, we'd have better outcomes," he adds.

In elderly patients, life expectancy varies considerably according to health status. For instance, a 74-year-old man who is in excellent health has a life expectancy of almost 15 years.

The study suggests the upper age cut-off could unintentionally discourage screening for these healthy, older individuals, leading them to miss out on the colorectal screenings known to prevent cancer. CRC screening tests include colonoscopy, sigmoidoscopy, and fecal occult blood testing.

"Future patient-centered quality measures should focus on clinical benefit rather than age to ensure that patients who are likely to benefit from screening receive it, regardless of age, and that those who are likely to incur harm are spared unnecessary and costly care," says senior study author Eve Kerr, M.D., M.P.H., director of VA-CCMR and professor of internal medicine at the U-M Health System.